Facing a three-month wait to get fillings at another dental practice, Carolyn Reigstad found herself at Aspen Dental in Grand Forks Friday morning.

"I'm going to have it done here now," she said.

Aspen Dental, a national chain with more than 500 locations, cited dental health professional shortages in North Dakota for its decision to open a Grand Forks location. But researchers said population centers like the city of Grand Forks aren't where North Dakota's need for dentists is most pronounced.

The U.S. Department of Health and Human Services designates roughly a dozen North Dakota counties as dental health professional shortage areas, and a 2014 report notes shortages tend to be in rural, underserved and Native American communities. Among the designated counties are Griggs, Steele and Nelson, which are south and west of Grand Forks, as well as the western portion of Grand Forks County.

Some dentists said the immediate area has plenty of providers, but researchers said the problem tends to hit rural areas. With just 50 percent of the state's population living in "urban" areas, 67 percent of dentists are located in Grand Forks, Cass, Burleigh and Ward counties, which include North Dakota's four largest cities, said Shawnda Schroeder, a research assistant professor at the Center for Rural Health at UND.

"What we have really is an issue of distribution of dentists," she said.

Urban vs. rural
Several dentists in Grand Forks said they don't consider the local community to have a shortage of dental professionals.

"There are plenty of dentists and plenty of dentists graduating," said Chelsea Erickson, a dentist at DeMers Dental in East Grand Forks. "The issue is there are certainly underserved areas—Grand Forks just doesn't happen to be one of them."

Grand Forks, Walsh and Ramsey counties have at least five dentists each, while Pembina and Traill counties have between two and four each. Griggs County and Cavalier have one dentist each, and there are no dentists in Nelson and Steele counties, according a 2014 report by Center for Rural Health.

Lack of immediate access to a dentist can mean long commutes to a nearby town, which can complicate work schedules and other obligations, Schroeder said.

Health professionals said the cost of operating a dental practice means there needs to be an available patient population to draw from.

"Either way, you have to have a full schedule," said Rob Lauf, a dentist with Goose River Dental in Mayville, N.D., who doesn't consider the eastern part of the state to have a dental shortage. "There are some counties that don't have a dentist, but they also don't have the population to support a dentist."

But it appears many North Dakota dentists do have a full schedule. An American Dental Association survey showed that less than 10 percent of general and specialist dentists in North Dakota reported they are not busy enough and could see more patients in 2013, which was the lowest percentage of the 36 states included on the survey and well below the national average of roughly 35 percent.

Dental needs aren't limited to rural areas in North Dakota. Just 7.8 percent of Minnesota's dentists are located in the northwest portion of the state, while 61.7 percent are in the Minneapolis-St. Paul area, according to the Minnesota Department of Health.

Other issues
In 2014, a division of the U.S. Department of Health and Human Services suggested it would take 7,300 dentists to eliminate health professional shortage area designations across the country.

But Marko Vujicic, chief economist with the ADA, called that a "highly flawed" figure. While he acknowledged rural areas face a lack of providers, he said the main reasons people don't seek dental care are cost and "a perceived lack of need" rather than an inability to get a dental appointment scheduled.

"So that gives me an aggregate picture of, 'Wait a minute, more dentists isn't going to solve that,'" he said.

Still, the national supply of dentists is expected to grow in the next 15 years. A 2014 report from the ADA that Vujicic co-authored predicted the number of dentists would increase to 63.3 per 100,000 people in 2033, up from 61.7 in 2013.

Dental care access isn't just a matter of location and supply of dentists, Schroeder said.

"Access to care is absolutely an issue, more significantly for those who are low-income, those who are on Medicaid, those who are rural, those who are aging, and American Indian," she said. "Those are the populations that are having worse oral health outcomes, and they are not utilizing dental care as readily."

The portion of North Dakota children with Medicaid coverage who have visited a dentist in the past year grew from 13 percent in 2000 to 33 percent in 2013, although it has dropped slightly in the years leading up to 2013, according to the Center for Rural Health. North Dakota is below the national rate of 48 percent of children with Medicaid coverage who recently saw a dentist in 2013, according to the ADA.

Solutions
Complicating North Dakota's supply of dentists is the lack of a dental school in the state. North Dakota instead relies on students trained at schools like the University of Minnesota and Creighton University in Nebraska, according to the Center for Rural Health.

To recruit dentists to North Dakota, the state offers a student loan repayment program for up to $100,000. Traditionally the program only receives a handful of applicants every year, but the state has become more aggressive in marketing it with the help of the North Dakota Dental Association, said Mary Amundson, associate professor at the UND School of Medicine and Health Sciences.

Brent Holman, executive director of the North Dakota Dental Association, said the state Legislature simplified and improved the loan repayment program last year, and now it's "among the most attractive in the nation."

"We certainly have students from North Dakota going to dental school outside the state," Amundson said. "We really try to focus on where our students go and then try and recruit them back as dental health care professionals to provide service in the state."

But other efforts to address rural dental care gaps have been met with skepticism.

Last year North Dakota legislators proposed allowing certified "advanced dental hygienists" to perform some procedures now done by dentists, a move they said could help ease dental care needs in rural and Native American communities. That bill was opposed by the North Dakota Dental Association and ultimately did not become law.

"We just didn't feel there was enough evidence that mid-level dental providers reduced cost, or improved oral health outcomes or maintained the quality of care in states similar to North Dakota," Holman said. He added that mid-level providers will have the same overhead concerns and population demands that dentists would face in rural areas.

"It goes back trying to recruit and market dentistry as a career for North Dakota students," Holman said. "Loan repayment has been a really good marketing tool because that shows students that there's a need for dentists and there probably always be in North Dakota."